Where you live and where people die

A new study has just been published to explore regional variations in geographic access to inpatient hospices and place of death. Emeka Chukwusa (Cicely Saunders Institute, London, UK) and Ros Taylor (Hospice UK and Royal Marsden Hospital, London, UK) explain the background to their longer article published open access in PLoS One. 

Dr Emeka Chukwusa (left) and Dr Ros Taylor.

The setting in which people die is important. It affects the quality of experience and is a preference we try to meet. But we need a good understanding of how geographic access to palliative and end-of-life care facilities affects where people die. Such knowledge is important to help guide care planning, reduce inequalities, and develop strategies to improve the experience of care in all settings.

In 2019, we conducted a study to explore urban-rural differencesin the association between geographic access to hospice and where people die. We discovered that patients who lived further away from inpatient hospices are more likely to die at home.Our study also revealed that urban dwellers had better access to inpatient hospices compared to rural dwellers. Most inpatient hospices in the UK are charitable and have arisen in affluent, large towns and cities. The intent is to target populations that can support their fundraising needs.

Transport links will obviously be better than in rural areas, supporting easier access. Motivated by this finding, we further examined regional differences in geographic access to inpatient hospice in England, UK. We used national death certificate data from 2014, comprising deceased adults (aged 25 years and above) who died at home and in inpatient hospices. Patients were grouped into one of the nine regions of England based on their residential addresses.

We used drive times as an indicator of geographic access. Drive times were calculated from the residential addresses of over 123,000 patients to 184 adult inpatient hospices. One can observe from the map below that access varied hugely across regions, with a marked north-south differential. 2

 Figure 1:  Geographic access to adult inpatient hospice unit. Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0231666

We then looked at regional variations in the association between geographic access to hospice and hospice deaths. Deaths in inpatient hospices were compared with home deaths. We found that increasing drive times from hospices reduced the chances of dying in a hospice. This decrease was more obvious in six regions.

Regional differences in geographic access to inpatient hospices highlight the need for a targeted approach to service improvement. People want to spend time with a loved one in their final days. However, the time spent travelling and physical distance will diminish the quality and quantity of time together. Although a hospice ending may be the preference – the geography makes it too difficult. The only option will be a home death, which may work well with enough support, or a hospital death, which research shows is the least preferred option for most. The implications are that ‘hospice at home’ palliative support may need to be geographically prioritised in areas furthest from an inpatient unit to ensure equal access to good end-of-life care. Other options might be enhanced palliative care in care homes in areas furthest from the local hospice.

Our study suggests that geography of hospices should be a key enabler of palliative and end-of-life care service planning.


1.Chukwusa, E., et al., Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK. Int J Health Geogr, 2019. 18 (1): p. 8.

2.Chukwusa, E., et al., Regional variations in geographic access to inpatient   hospices and Place of death: A Population-based study in England, UK. PLoS   One, 2020. 15 (4): p. e0231666.

More about the authors…

Dr Emeka Chukwusa is a Research Associate at Cicely Saunders Institute, King’s College London, UK. Dr Ros Taylor is a palliative care doctor at Hospice UK and Royal Marsden Hospital, London UK. Follow Ros on Twitter at @hospicedoctor

This work is part of The GUIDE CARE Services project – set up to describe variations in place of death and the factors that affect these in order to guide ways to improve the quality of care at the end of life. This project is partly supported by the National Institute for Health Research (NIHR) Applied Research Collaborations (ARC) South London. ARC South London is part of the National Institute for Health Research (NIHR) – more information here.


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